Primary prevention

Patient and family/carer education

Ensure that the patient and their family or carers understand:

  • How to recognise signs and symptoms of hypoglycaemia.[1][2]​​

  • How to treat an episode of hypoglycaemia with glucose and glucagon.[2] Note that administration of glucagon is not limited to healthcare professionals and may be given by family or carers if needed; anyone who is in close contact with a patient who is prone to hypoglycaemia (e.g., family members, room-mates, school personnel, childcare providers, correctional institution staff, or co-workers) should be educated on how to administer glucagon.​[3][38][59]​​​ Ensure that glucagon is prescribed for all patients at risk of level 2 (clinically significant; also referred to as clinically important or serious) or level 3 (severe) hypoglycaemia.[3] Level 2 hypoglycaemia is defined as blood glucose <3.0 mmol/L (<54 mg/dL).​[1][3][4][17]​​​ Level 3 hypoglycaemia is a severe event characterised by altered mental and/or physical status requiring assistance for treatment of hypoglycaemia.​[1][3][4][17]

  • Circumstances in which the patient is at increased risk of hypoglycaemia (e.g., when fasting for laboratory tests or procedures, when meals are delayed, during and after the consumption of alcohol, during and after intense exercise, during sleep).​[1][3]​​​[17][38]​ Educate the patient and their family or carers on how to adjust their insulin doses in these scenarios to reduce the risk of hypoglycaemia.[37][38]

Patients may benefit from formal training programmes, including structured education on flexible insulin use, to increase awareness of, and prevent, hypoglycaemia.​[2][3]​​​[4][17][59][72]​​​​ Children and young people with diabetes should also have a school healthcare plan detailing their current diabetic treatments, and this should be reviewed by their diabetes team at least once a year.[38]

Dietary intervention

All patients taking antidiabetic drugs should carry carbohydrates with them at all times, and understand the effect of the carbohydrate on their blood glucose.[1][2] They should be aware of which foods contain carbohydrates.[2] If a patient is taking long-acting secretagogues or a fixed insulin regimen, encourage them to follow a predictable meal plan.[2] If a patient is on a flexible insulin regimen, ensure that they understand that insulin injections should be matched to meal times.[2]

Exercise management

Patients should check their blood glucose before exercising and consume extra carbohydrates based on their blood glucose level (particularly if this is falling) and the planned duration and intensity of exercise.[1][2][37][38]​ Hypoglycaemia leading up to physical activity increases the risk of exercise-induced hypoglycaemia, and patients should usually be advised against exercising within 24 hours of a severe hypoglycaemic episode.[37]​ Patients should also ensure that they have fast-acting carbohydrates with them at all times when exercising.[2][38]​​ If a patient is taking insulin, they should consider adjusting the insulin doses on the days when exercise is planned.[2][37]​ Patients who increase their activity levels over time may experience a reduction in their overall insulin requirements due to the sustained increase in insulin sensitivity, and should have insulin dose adjustments made as necessary by their diabetes team to avoid hypoglycaemia.[37]​ Patients should also be advised not to consume alcohol where possible on days they are exercising.[37]​ The International Society for Pediatric and Adolescent Diabetes advocates that exercise planning should be individualised, reviewed often, and have a focus on hypoglycaemia avoidance strategies.[37]​ Athletes using insulin should be managed by a diabetes team with consultant exercise knowledge.[37]

Medication

In patients with type 2 diabetes, consider the effect of their antidiabetic medication on their risk of hypoglycaemia.[73] Drugs that are associated with increased risk of hypoglycaemia include insulin, sulfonylureas, and meglitinides, and combinations of these drugs are not usually recommended.[17][73]​​​​ Conversely, metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors are associated with low risk of hypoglycaemia.[73][74]​​​

It should be noted that different types or formulations of insulin may be associated with increased risks of hypoglycaemia.[75]​ For example, premixed insulin injections (which combine short-acting and long-acting insulin) may have a higher hypoglycaemia risk, and it is harder for patients to adjust their dose.[73]​[75]​ For adults and children who are taking insulin and at high risk of hypoglycaemia, guidance from the Endocrine Society recommends using:[17]

  • Long-acting insulin analogues instead of human neutral protamine Hagedorn (NPH) insulin if they are on basal insulin therapy

  • Rapid-acting insulin analogues rather than regular (short-acting) human insulins if they are on basal-bolus insulin therapy.

Blood glucose monitoring

Blood glucose monitoring is key for prevention of hypoglycaemia in all patients with type 1 diabetes, and may be appropriate for some patients with type 2 diabetes.​[2][3][4][76][77]​​​​ See Monitoring.

Secondary prevention

​Take appropriate action, depending on the underlying cause of hypoglycaemia, to mitigate against further episodes of hypoglycaemia.[1]​ Measures used should be in addition to those used for primary prevention.

Adjust the patient's treatment for diabetes based on their risk of hypoglycaemia.​[2][3]​​ This is particularly important if they have impaired awareness of hypoglycaemia.[3]

  • Review the patient's blood glucose patterns, which may suggest periods of the day where they are at risk of hypoglycaemia.[2]

  • If the patient has recurrent hypoglycaemia and type 1 diabetes, consider strategies such as adjustment of the patient's insulin regimen (e.g., use of flexible insulin or insulin analogue regimens, substitution of rapid-acting insulin for neutral insulin), as well as incorporating diabetes technology (e.g., insulin pumps, continuous glucose monitoring) to monitor and deliver insulin more effectively.[1][2][4][38]​​​[59]​​ Examples of technology used in diabetes management include sensor-augmented pump therapy (where insulin pump therapy is suspended if hypoglycaemia is predicted based on patient-specific set glucose limits) and closed-loop systems (which use a control algorithm that autonomously and continually increases and decreases the delivery of insulin based on real-time sensor blood glucose levels, rather than patient intervention).[1] Some trials and studies have shown that these technologies can reduce the time spent in a hypoglycaemic range (blood glucose <3.9 mmol/L [<70 mg/dL]).[1][132]​​​[133]

  • Newer technologies (such as artificial pancreas systems) have been shown to improve glucose control and reduce hypoglycaemic events in outpatient settings compared to conventional pump therapy.[1] Pancreas and islet cell transplantation may also be used in certain patients, which can improve glycaemic control and survival rates.[134][135]​​​

  • If the patient has recurrent hypoglycaemia and type 2 diabetes, avoid antidiabetic drugs that increase the risk of hypoglycaemia (e.g., insulin, sulfonylureas, and meglitinides). Conversely, metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors are associated with low risk of hypoglycaemia.[73][74]​​​​ Due to the risk of hypoglycaemia associated with insulin, NICE guidance emphasises avoiding insulin where possible in paediatric patients with type 2 diabetes, instead giving preference to oral antidiabetic drugs that are low risk for hypoglycaemia.[38] They also recommend downtitration or withdrawal of insulin therapy in this group of patients when possible.[38]​

If the patient has prolonged nocturnal hypoglycaemia, consider increased monitoring of overnight blood glucose levels.[1]

Review the patient's food intake, particularly the fat and protein content of meals.[1][59]​ Consider adding daytime and bedtime snacks if they are taking intermediate-acting insulin.[1]

If hypoglycaemia is related to exercise, consider:[1]

  • Snacks before and after exercise[1][37]​

  • Suspension (or reduction) of the patient's insulin pump before exercise if they are using one[1][37]​​

  • Addition of extra carbohydrates if they are taking insulin and are exercising at peak action of insulin[1][37]​

  • 10-second maximum intensity activity at the end of the exercise session (e.g., sprint).[136]

If a patient has impaired awareness of hypoglycaemia, consider short-term relaxation of glycaemic targets; several weeks of avoidance of hypoglycaemia has been shown to improve counter-regulatory hormone response and impaired awareness of hypoglycaemia.​[1][3]

Patients may benefit from formal training programmes, including structured education on flexible insulin use, to increase awareness of, and prevent, hypoglycaemia.​[2][3][4]​​[59][72]​​​​ For example, the Blood Glucose Awareness Training Program may be useful for patients with recurrent episodes of hypoglycaemia.​[2][3][17][59]​​​

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